Repositorio de Reportes de Biopsias Oncológicas, published by Unidad de Interoperabilidad - MINSAL. This guide is not an authorized publication; it is the continuous build for version 0.1.1-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Minsal-CL/R2BO/ and changes regularly. See the Directory of published versions

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: Informe de Anatomía Patológica de Biopsia de Mama - JSON Representation

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{
  "resourceType" : "DiagnosticReport",
  "id" : "r2bo-informe-biopsia-ex",
  "meta" : {
    "profile" : [
      🔗 "https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-informe-biopsia"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: InformeDiagnostico r2bo-informe-biopsia-ex</b></p><a name=\"r2bo-informe-biopsia-ex\"> </a><a name=\"hcr2bo-informe-biopsia-ex\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-r2bo-informe-biopsia.html\">Perfil del Reporte de Anatomía Patológica</a></p></div><h2><span title=\"Codes:{http://loinc.org 66110-8}\">Informe de Biopsia de Mama</span> (<span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 PAT}\">Pathology (gross &amp; histopath, not surgical)</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td>Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876\u00a0(use:\u00a0official,\u00a0))</td></tr><tr><td>Reported</td><td>2021-08-01 10:00:00-0400</td></tr><tr><td>Performer</td><td> <a href=\"PractitionerRole-r2bo-anatopatologo-hospital.html\">PractitionerRole MÉDICO CIRUJANO</a></td></tr><tr><td>Identifier</td><td> r2bo-2020-0001</td></tr></table><p><b>Report Details</b></p><table class=\"grid\"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Flags</b></td><td><b>When For</b></td></tr><tr><td><a href=\"Observation-r2bo-observacion-microscopica-ex.html\"><span title=\"Codes:{http://loinc.org 102034-6}\">Pathology report microscopic observation in Specimen</span></a></td><td>Se observa tejido mamario con células epiteliales y estromales, con signos de malignidad con metastasis en ganglios linfáticos</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-macroscopica-ex.html\"><span title=\"Codes:{http://loinc.org 74574-5}\">Observación macroscópica: XXX : Punto temporal: Impresión / interpretación del estudio: Narrativo:</span></a></td><td>Muestra de biopsia de tejido mamario, de 2x2x1 cm, de color blanco, consistencia firme, bordes irregulares, sin lesiones visibles a simple vista</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-estadificacion-tnm-ex.html\"><span title=\"Codes:{http://snomed.info/sct 399588009}\">Pathologic TNM stage grouping</span></a></td><td/><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-ganglios-linfaticos-ex.html\"><span title=\"Codes:{http://loinc.org 92831-7}\">Ganglios linfáticos con metástasis: Espécimen de cáncer : Punto temporal: Número (recuento): Cuantitativo:</span></a></td><td>true</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-infiltracion-perineural-ex.html\"><span title=\"Codes:{http://snomed.info/sct 371513001}\">Presence of direct invasion by primary malignant neoplasm to nerve</span></a></td><td><span title=\"Codes:{http://snomed.info/sct 385001000}\">Perineural invasion by tumour not identified</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-infiltracion-peritumoral-ex.html\"><span title=\"Codes:{http://snomed.info/sct 371509008}\">Status of peritumoral lymphocyte response</span></a></td><td><span title=\"Codes:{http://snomed.info/sct 369762001}\">Marked peritumoral lymphocytic response</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-invasion-linfatica-ex.html\"><span title=\"Codes:{http://loinc.org 33739-4}\">Invasión linfática de vasos subs: Muestra : Punto temporal: Presencia o identidad: Nominal: Protocolos de cáncer de CAP</span></a></td><td><span title=\"Codes:{http://snomed.info/sct 52101004}\">Present</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-invasion-vascular-ex.html\"><span title=\"Codes:{http://loinc.org 33740-2}\">Invasión de vasos grandes venosos: Muestra : Punto temporal: Presencia o identidad: Nominal: Protocolos de cáncer de CAP</span></a></td><td><span title=\"Codes:{http://snomed.info/sct 52101004}\">Present</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-margen-quirurgico-ex.html\"><span title=\"Codes:{http://snomed.info/sct 396631001}\">Surgical margin observable</span></a></td><td/><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-centricidad-ex.html\"><span title=\"Codes:{http://loinc.org 42030-7}\">Múltiples tumores informados como primarios únicos:Cancer.XXX :Punto temporal:Tipo:Nominal:</span></a></td><td>true</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-multifocalidad-ex.html\"><span title=\"Codes:{http://snomed.info/sct 444696007}\">Status of specimen involvement by multifocal invasion</span></a></td><td>true</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-porcentaje-necrosis-ex.html\"><span title=\"Codes:{http://snomed.info/sct 405921002}\">Percentage of tumour involved by necrosis</span></a></td><td>5 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = 'percent')</span></td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-observacion-post-tratamiento-neoadjuvancia-ex.html\"><span title=\"Codes:{http://loinc.org 84891-1}\">Respuesta a la terapia neoadyuvante: Muestra de cáncer colorrectal : Punto temporal: Presencia o umbral: Ordinal:</span></a></td><td>El tratamiento entregado no ha sido efectivo para reducir el tamaño del tumor, por lo que se recomienda un nuevo tratamiento.</td><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr><tr><td><a href=\"Observation-r2bo-tamano-tumor-ex.html\"><span title=\"Codes:{http://loinc.org 21889-1}\">Tamaño:Tumor :Punto temporal:Len:Cuantitativo:</span></a></td><td/><td>Final</td><td>2021-06-01 12:00:00-0400</td></tr></table><p>Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral</p><p><b>Coded Conclusions:</b></p><ul><li><span title=\"Codes:{http://snomed.info/sct 82711006}, {http://terminology.hl7.org/CodeSystem/icd-o-3 8500/3}\">Carcinoma ductal infiltrante</span></li><li><span title=\"Codes:{http://snomed.info/sct 76752008}, {http://terminology.hl7.org/CodeSystem/icd-o-3 C50.9}\">Mama</span></li></ul></div>"
  },
  "extension" : [
    {
      "url" : "https://interoperabilidad.minsal.cl/fhir/ig/r2bo/StructureDefinition/r2bo-extension-referencia-composition",
      "valueReference" : {
        🔗 "reference" : "Composition/r2bo-documento-biopsia-ex"
      }
    }
  ],
  "identifier" : [
    {
      "value" : "r2bo-2020-0001"
    }
  ],
  "basedOn" : [
    {
      🔗 "reference" : "ServiceRequest/r2bo-solicitud-informe-apa-ej"
    }
  ],
  "status" : "final",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code" : "PAT",
          "display" : "Pathology (gross & histopath, not surgical)"
        }
      ]
    }
  ],
  "code" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "66110-8"
      }
    ],
    "text" : "Informe de Biopsia de Mama"
  },
  "subject" : {
    🔗 "reference" : "Patient/paciente-requiere-examen"
  },
  "issued" : "2021-08-01T10:00:00-04:00",
  "performer" : [
    {
      🔗 "reference" : "PractitionerRole/r2bo-anatopatologo-hospital"
    }
  ],
  "specimen" : [
    {
      🔗 "reference" : "Specimen/r2bo-specimen-example"
    }
  ],
  "result" : [
    {
      🔗 "reference" : "Observation/r2bo-observacion-microscopica-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-macroscopica-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-estadificacion-tnm-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-ganglios-linfaticos-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-infiltracion-perineural-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-infiltracion-peritumoral-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-invasion-linfatica-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-invasion-vascular-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-margen-quirurgico-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-centricidad-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-multifocalidad-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-porcentaje-necrosis-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-observacion-post-tratamiento-neoadjuvancia-ex"
    },
    {
      🔗 "reference" : "Observation/r2bo-tamano-tumor-ex"
    }
  ],
  "conclusion" : "Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral",
  "conclusionCode" : [
    {
      "id" : "Morfologico",
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "82711006"
        },
        {
          "system" : "http://terminology.hl7.org/CodeSystem/icd-o-3",
          "code" : "8500/3"
        }
      ],
      "text" : "Carcinoma ductal infiltrante"
    },
    {
      "id" : "Topografico",
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "76752008"
        },
        {
          "system" : "http://terminology.hl7.org/CodeSystem/icd-o-3",
          "code" : "C50.9"
        }
      ],
      "text" : "Mama"
    }
  ]
}